NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:
Correct Answer: C
Rationale: Pericarditis can cause dyspnea but primarily causes chest pain. Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position.
Question 2 of 5
The nurse has performed discharge teaching to a client in need of a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan?
Correct Answer: B
Rationale: A high-iron diet includes iron-rich foods like veal and spinach. Sliced veal, spinach salad, and whole-wheat roll (
B) are optimal. Other options lack significant iron sources.
Question 3 of 5
Following eruption of the primary teeth, the mother can promote chewing by giving the toddler:
Correct Answer: C
Rationale: Pieces of cereal are soft, small, and safe for a toddler to chew, promoting jaw development without posing a choking hazard, unlike hot dogs, carrot sticks, or raisins.
Question 4 of 5
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
Correct Answer: B
Rationale: Exudate (moist, active drainage) is a clinical sign of wound infection. Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. Edema (swelling) is a clinical sign of wound infection. Erythema (redness) is a clinical sign of wound infection.
Question 5 of 5
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
Correct Answer: C
Rationale: This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. Sacral pressure will counteract the pressure created by the position of the fetal head. The client is not completely dilated. Pushing is contraindicated until the second stage of labor.